3-Year Outcomes After Valve-in-Valve Transcatheter Aortic Valve Replacement for Degenerated Bioprostheses: The PARTNER 2 Registry

Impact of Elevated Gradients After Transcatheter Aortic Valve Implantation for Degenerated Surgical Aortic Valve Bioprostheses

BACKGROUND

Elevated aortic valve gradients are common after transcatheter aortic valve implantation for degenerated surgical aortic valve replacement bioprostheses, but their clinical impact is uncertain.

METHODS

A total of 12 122 patients who underwent transcatheter aortic valve implantation-in-surgical aortic valve replacement from November 2011 to December 2019 in the Society of Thoracic Surgery/American College of Cardiology Transvalvular Therapeutics Registry were included. The primary outcome was a composite of 1-year all-cause mortality, stroke, myocardial infarction, or valve reintervention. Secondary outcomes included 1-year all-cause mortality, readmission, and change from baseline 12-question self-administered Kansas City Cardiomyopathy Questionnaire-Overall Summary Score. Due to nonlinearity observed with restricted cubic splines analysis, a Cox regression analysis with aortic valve mean gradient modeled as a spline-continuous variable (with 20 mm Hg as a cutoff) was used to study the 1-year composite outcome and mortality.

RESULTS

The composite outcome occurred most frequently in patients with aortic valve mean gradient ≥30 and <10 mm Hg, as compared with those with 10 to 20 and 20 to 30 mm Hg ranges (unadjusted rates, 13.9%, 12.1%, 7.5%, and 6.5%, respectively; P=0.002). When the mean aortic valve gradient was ≥20 mm Hg, higher gradients were associated with greater risk of the 1-year composite outcome (adjusted hazard ratio, 1.02 [1.02-1.03] per mm Hg; P<0.001) and 1-year mortality (adjusted hazard ratio, 1.02 [1.00-1.03] per mm Hg; P=0.007). Whereas when the mean aortic valve gradient was <20 mm Hg, higher gradients were not significantly associated with the composite outcome (adjusted hazard ratio, 0.99 [0.98-1.003] per mm Hg; P=0.12) but were associated with lower 1-year mortality (adjusted hazard ratio, 0.98 [0.97-0.99] per mm Hg; P=0.007).

CONCLUSIONS

The relationship between postprocedural aortic valve mean gradient after transcatheter aortic valve implantation-in-surgical aortic valve replacement and clinical outcomes is complex and nonlinear, with relatively greater adverse events occurring at low and high gradient extremes. Further study of factors mediating the relationship between postprocedural gradients and clinical outcomes, including low-flow states, is necessary.

Self-expandable transcatheter valve is a potentially useful option for a failing small surgical aortic bioprosthetic valve

OBJECTIVE

Trans-catheter aortic valve implantation inside a failing surgical aortic valve bio-prosthesis has become an alternative for patients at high risk for redo surgical aortic valve replacement. However, the correlation between the size of the failing surgical aortic valve and the occurrence of prosthesis-patient mismatch after trans-catheter implantation is still controversial. The aim of this study is to analyze and report the results in Japanese patients.

METHODS

Thirty patients who underwent trans-catheter aortic valve implantation inside a failing surgical aortic valve at our hospital were retrospectively reviewed with results from echocardiography and computed tomography.

RESULTS

The patients' mean age was 84.5 ± 4.8 years. The mean body surface area was 1.42 ± 0.13 m2. The cohort was divided into two groups according to the size of the failing bio-prosthesis: small (≦19 mm) and large (> 19 mm). There were no significant differences in mean pressure gradient (12.2 ± 4.0 mmHg vs. 11.1 ± 1.2 mmHg; p = 0.54) and effective orifice area index (1.00 ± 0.26 cm2/m2 vs. 0.99 ± 0.25 cm2/m2; p = 0.92) between the groups at 6 months after trans-catheter implantation. The incidence of moderate (38.5% vs. 28.6%; p = 0.59) and severe (0% vs. 7.1%; p = 0.33) prosthesis-patient mismatch was equivalent. There was no significant difference in survival between the two groups (log-rank test p-value = 0.08).

CONCLUSIONS

Trans-catheter implantation inside a failing small aortic valve did not increase the frequency of prosthesis-patient mismatch in this Japanese cohort.

Transcatheter Aortic Valve Implantation for Severe Chronic Aortic Regurgitation

Transcatheter aortic valve implantation (TAVI) has revolutionised the management of aortic valve disease, offering a less invasive alternative to traditional surgical valve replacement for severe aortic stenosis (AS). TAVI for pure aortic regurgitation (AR) is less well established, and, in fact, it was previously labelled as a relative contraindication. However, TAVI has been utilised for selected cases of pure or predominant AR. The primary limitations regarding the use of TAVI in AR are related to the absence of anatomical factors seen in patients with AS that have contributed to the safe and stable functioning of current-generation prostheses. These include aortic root dilatation, mobile valve leaflets and labile blood pressure within the aortic root, which may further increase the risk of valve migration and periprosthetic leak after deployment. Furthermore, patients with AR have more heterogeneous aortic root anatomies when compared to the population of patients with calcific or degenerative AS. This review article describes the current evidence for the off-label use of TAVI in pure AR and the various clinical syndromes associated with AR where there may be specific challenges in the application of TAVI.

Optimising percutaneous valve-in-valve TAVI with bioprosthetic valve fracture

Percutaneous transcatheter aortic valve implantation (TAVI) has become an established therapy for inoperable patients, for high, intermediate and low surgical-risk patients over 65 years old with severe aortic valve stenosis (AS).1,2 Valve-in-valve (ViV) TAVI is an approved indication for patients with degenerated aortic surgical bioprostheses.

New Insights and Perspective on Bioprosthetic Valve Fracture From Bench Testing and Computed Tomography Analysis

Background

Bioprosthetic valve fracture (BVF) during valve-in-valve TAVR (transcatheter aortic valve replacement) is a procedural adjunct designed to optimize the expansion of the transcatheter heart valve and reduce patient-prosthesis mismatch by using a high-pressure balloon to intentionally fracture the surgical heart valve (SHV).

Methods

We performed bench testing on 15 bioprosthetic SHV to examine the optimal balloon size and pressure for BVF. We assessed morphological changes and expansion of SHV by computed tomography angiography. Successful BVF was defined as balloon waist disappearance on fluoroscopy and/or sudden pressure drop during balloon inflation.

Results

Nine valves met the definition of BVF, 3 of which were confirmed by disruption of the stent frame. We classified surgical valves into 3 subsets: 1) fracturable with metal stent frame (MSF), 2) fracturable with polymer stent frame (PSF) and 3) nonfracturable. In general, valves with MSF were fractured using a balloon size = true internal diameter plus 3-5 mm inflated at high pressure (16-20 ATM) whereas valves with PSF could be fractured with a balloon size = true internal diameter plus 3-5 mm and lower balloon pressure (6-14 ATM). Gains in computed tomography angiography derived inflow area after BVF were 12.3% for MSF and 3.6% for PSF SHV.

Conclusions

Gains in CT-determined valve area after BVF depend on the physical properties of the SHV, which in turn influences pressure thresholds and balloon sizing strategy for optimal BVF. Elastic recoil of PSF valves limits the gains in inflow area after BVF.

Ten-Year Long-Term Analysis of Mechanical and Biological Aortic Valve Replacement

BACKGROUND

 For patients undergoing aortic valve replacement (AVR), structural valve deterioration (SVD) of a bioprosthesis (BP) is substantially accelerated in younger patients and valve-in-valve implantation is not always a considerable option. The risk-benefit assessment between SVD versus the risk of bleeding and thromboembolic events in patients with a mechanical prosthesis (MP) resulted in an age limit shift irrespective of inconsistent results reported in literature.

METHOD

 This retrospective single-center study compared 10-year long-term outcomes in patients undergoing isolated AVR with MP or BP. The risk-adjusted comparison of patients undergoing isolated AVR (n = 121) was performed after 1:1 propensity score matching (PSM) for age, sex, endocarditis, and chronic renal impairment (caliper of 0.2) leading to 29 pairs. Short- and long-term outcomes with respect to reoperation, major bleeding, stroke, all-cause and cardiovascular mortality, and overall survival at 10 years were analyzed.

RESULTS

 After PSM, groups were comparable with respect to preoperative characteristics, including patients with a mean age of 65 ± 3 years (MP) and 66 ± 4 years (BP) and an incidence rate of 6.9% for infective endocarditis in both cohorts. Short-term outcomes (transient neurologic disorder = 0.0 vs. 6.9%; stroke = 0.0%; in-hospital mortality = 3.4%) and in-hospital stays were comparable between MP and BP.

CONCLUSION

 After isolated AVR with MP and BP, 10-year long-term outcomes were comparable in the reported single-center cohort. MP can still be implanted safely without a disadvantage as regards long-term survival.

Outcomes of Valve-in-Valve Transcatheter Aortic Valve Replacement

Structural valve degeneration is increasingly seen given the higher rates of bioprosthetic heart valve use for surgical and transcatheter aortic valve replacement (TAVR). Valve-in-valve TAVR (VIV-TAVR) is an attractive alternate for patients who are otherwise at high risk for reoperative surgery. We compared patients who underwent VIV-TAVR and native valve TAVR through a retrospective analysis of our institutional transcatheter valve therapy (TVT) database from 2013 to 2022. Patients who underwent either a native valve TAVR or VIV-TAVR were included. VIV-TAVR was defined as TAVR in patients who underwent a previous surgical aortic valve replacement. Kaplan-Meier survival analysis was used to obtain survival estimates. A Cox proportional hazards regression model was used for the multivariable analysis of mortality. A total of 3,532 patients underwent TAVR, of whom 198 (5.6%) underwent VIV-TAVR. Patients in the VIV-TAVR cohort were younger than patients who underwent native valve TAVR (79.5 vs 84 years, p <0.001), with comparable number of women and a higher Society of Thoracic Surgeons risk score (6.28 vs 4.46, p <0.001). The VIV-TAVR cohort had a higher incidence of major vascular complications (2.5% vs 0.8%, p = 0.008) but lower incidence of permanent pacemaker placement (2.5% vs 8.1%, p = 0.004). The incidence of stroke was comparable between the groups (VIV-TAVR 2.5% vs native TAVR 2.4%, p = 0.911). The 30-day readmission rates (VIV-TAVR 7.1% vs native TAVR 9%, p = 0.348), as well as in-hospital (VIV-TAVR 2% vs native TAVR 1.4%, p = 0.46), and overall (VIV-TAVR 26.3% vs native TAVR 30.8%, p = 0.18) mortality at a follow-up of 1.8 years (0.83 to 3.5) were comparable between the groups. The survival estimates were also comparable between the groups (log-rank p = 0.27). On multivariable Cox regression analysis, VIV-TAVR was associated with decreased hazards of death (hazard ratio 0.68 [0.5 to 0.9], p = 0.02). In conclusion, VIV-TAVR is a feasible and safe strategy for high-risk patients with bioprosthetic valve failure. There may be potentially higher short-term morbidity with VIV-TAVR, with no overt impact on survival.

Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography

In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgitation, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-dimensional transesophageal echocardiography for further refinement of valve morphology and function when needed. More recently, advances in computed tomography and cardiac magnetic resonance have enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardiographic techniques used and provides recommendations and general guidelines for evaluation of prosthetic valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline discusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.

Transcatheter aortic valve replacement: Past, present, and future

Transcatheter aortic valve replacement (TAVR) has emerged as a ground-breaking, minimally invasive alternative to traditional open-heart surgery, primarily designed for elderly patients initially considered unsuitable for surgical intervention due to severe aortic stenosis. As a result of successful large-scale trials, TAVR is now being routinely applied to a broader spectrum of patients. In deciding between TAVR and surgical aortic valve replacement, clinicians evaluate various factors, including patient suitability and anatomy through preprocedural imaging, which guides prosthetic valve sizing and access site selection. Patient surgical risk is a pivotal consideration, with a multidisciplinary team making the ultimate decision in the patient's best interest. Periprocedural imaging aids real-time visualization but is influenced by anaesthesia choices. A comprehensive postprocedural assessment is critical due to potential TAVR-related complications. Numerous trials have demonstrated that TAVR matches or surpasses surgery for patients with diverse surgical risk profiles, ranging from extreme to low risk. However, long-term follow-up data, particularly in low-risk cases, remains limited, and the applicability of published results to younger patients is uncertain. This review delves into key TAVR studies, pinpointing areas for potential improvement while delving into the future of this innovative procedure. Furthermore, it explores the expanding role of TAVR technology in addressing other heart valve replacement procedures.

Balloon- vs Self-Expanding Transcatheter Valves for Failed Small Surgical Aortic Bioprostheses: 1-Year Results of the LYTEN Trial

BACKGROUND

Data comparing valve systems in the valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) field have been obtained from retrospective studies.

OBJECTIVES

The authors sought to compare the 1-year hemodynamic performance and clinical outcomes between balloon-expandable valves (BEV) SAPIEN 3/ULTRA (Edwards Lifesciences) and self-expanding valves (SEV) Evolut R/PRO/PRO+ (Medtronic) in ViV-TAVR.

METHODS

Patients with a failed small (≤23 mm) surgical valve undergoing ViV-TAVR were randomized to receive a SEV or a BEV. Patients had a clinical and valve hemodynamic (Doppler echocardiography) evaluation at 1-year follow-up. Study outcomes were defined according to VARC-2/VARC-3 criteria. Intended performance of the valve was defined as mean gradient <20 mm Hg, peak velocity <3 m/s, Doppler velocity index ≥0.25 and less than moderate AR.

RESULTS

A total of 98 patients underwent ViV-TAVR (46 BEV, 52 SEV). At 1-year follow-up, patients receiving a SEV had a lower mean transaortic gradient (22 ± 8 mm Hg BEV vs 14 ± 7 mm Hg SEV; P < 0.001), and a higher rate of intended valve performance (BEV: 30%, SEV:76%; P < 0.001). There were no cases of greater than mild aortic regurgitation. There were no differences in functional status (NYHA functional class >II, BEV: 7.3%, SEV: 4.1%; P = 0.505) or quality of life (Kansas City Cardiomyopathy Questionnaire, BEV: 77.9 ± 21.2, SEV: 81.8 ± 14.8; P = 0.334). No differences in all-cause mortality (BEV: 6.5%, SEV: 3.8; P = 0.495), heart failure hospitalization (BEV: 6.5%, SEV: 1.9%; P = 0.214), stroke (BEV: 0%, SEV: 1.9%; P = 0.369), myocardial infarction (BEV: 0%, SEV: 1.9%; P = 0.347), or pacemaker implantation (BEV: 2.2%, SEV: 1.9%; P = 0.898) were found.

CONCLUSIONS

In patients who underwent ViV-TAVR for failed small aortic bioprostheses, those receiving a SEV exhibited a better valve hemodynamic profile at 1-year follow-up. There were no differences between SEV and BEV regarding functional status, quality of life, or clinical outcomes.

Identification of CT-derived Internal Area in Failed Surgical Stented Bioprostheses for Valve-in-Valve Implantation

In participants who underwent valve-in-valve transcatheter aortic valve replacement, hypoattenuating intra-annular material within the failed surgical bioprostheses reduced the CT-derived internal area and interfered with expansion of intra-annular-positioned implanted valves, leading to postprocedural patient-prosthesis mismatch.

The decreasing risk of reoperative aortic valve replacement: Implications for valve choice and transcatheter therapy

OBJECTIVE

Increasing use of bioprostheses for surgical aortic valve replacement (SAVR) in younger patients, together with wider use of transcatheter aortic valve replacement, necessitates understanding risks associated with surgical valve reintervention. Therefore, we sought to identify risks of reoperative SAVR compared with those of primary isolated SAVR.

METHODS

From January 1980 to July 2017, 7037 patients underwent nonemergency isolated SAVR, with 753 reoperations and 6284 primary isolated operations. These 2 groups were propensity score-matched on 46 preoperative variables, yielding 581 patient pairs for comparing outcomes.

RESULTS

Among propensity score-matched patients, aortic clamp time (median 63 vs 52 minutes; P < .0001), cardiopulmonary bypass time (median 88 vs 67 minutes; P < .0001), and postoperative stay (median 7.1 vs 6.9 days; P = .003) were longer for reoperative SAVR than primary isolated SAVR. Hospital mortality after reoperative SAVR decreased from 3.4% in 1985 to 1.3% in 2011, similar to that of primary isolated SAVR. Occurrence of stroke, deep sternal wound infection, and new renal dialysis was similar. Blood transfusion (67% vs 36%; P < .0001) and reoperations for bleeding/tamponade (6.4% vs 3.1%; P = .009) were more common after reoperative SAVR. Survival at 1, 5, 10, and 20 years was 94%, 82%, 64%, and 33% after reoperative SAVR and 95%, 86%, 72%, and 46% after elective primary isolated SAVR.

CONCLUSIONS

Risk of mortality and morbidity after reoperative SAVR has declined and is now similar to that of primary isolated SAVR. Decisions regarding prosthesis choice and SAVR versus transcatheter aortic valve replacement should be made in the context of lifelong disease management rather than avoidance of reoperation.

Computed tomography to guide transcatheter aortic valve implantation

Since its introduction in 2022, transcatheter aortic valve implantation (TAVI) has revolutionized the treatment and prognosis of patients with aortic stenosis. Robust clinical trial data and a wealth of scientific evidence support its efficacy and safety. One of the key factors for success of the TAVI procedure is careful preprocedural planning using imaging. Computed tomography (CT) has developed into the standard imaging method for comprehensive patient assessment in this context. Suitability of the femoral and iliac arteries for transfemoral access, exact measurement of aortic annulus size and geometry as the basis for prosthesis selection, quantification of the spatial relationship of the coronary ostia to the aortic annular plane, and identification of optimal fluoroscopic projection angles for the implantation procedure are among the most important information that can be gained from preprocedural CT. Further research is aimed at improving risk stratification, for example, with respect to annular perforation, periprosthetic aortic regurgitation, and need for postprocedural implantation of a permanent pacemaker.

Outcomes of Bioprosthetic Valve Fracture in Patients Undergoing Valve-in-Valve TAVR

BACKGROUND

Valve-in-valve (VIV) transcatheter aortic valve replacement (TAVR) is increasingly used to treat degenerated surgical bioprostheses. Bioprosthetic valve fracture (BVF) has been shown to improve hemodynamic status in VIV TAVR in case series. However, the safety and efficacy of BVF are unknown.

OBJECTIVES

The primary objective of this study was to assess the safety and efficacy of VIV TAVR using SAPIEN 3 and SAPIEN 3 Ultra valves with or without BVF using data from the Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry.

METHODS

The primary outcome was in-hospital mortality. Secondary outcomes included echocardiography-derived valve gradient and aortic valve area. Inverse probability of treatment weighting was used to adjust for baseline characteristics.

RESULTS

A total of 2,975 patients underwent VIV TAVR from December 15, 2020, to March 31, 2022. BVF was attempted in 619 patients (21%). In adjusted analyses, attempted BVF was associated with higher in-hospital mortality (OR: 2.51; 95% CI: 1.30-4.84) and life-threatening bleeding (OR: 2.55; 95% CI: 1.44-4.50). At discharge, VIV TAVR with attempted BVF was associated with larger aortic valve area (1.6 cm² vs 1.4 cm²; P < 0.01) and lower mean gradient (16.3 mm Hg vs 19.2 mm Hg; P < 0.01). When BVF was compared with no BVF according to timing (before vs after transcatheter heart valve implantation), BVF after transcatheter heart valve implantation was associated with improved hemodynamic status and similar mortality.

CONCLUSIONS

BVF as an adjunct to VIV TAVR with the SAPIEN 3 and SAPIEN 3 Ultra valves is associated with a higher risk for in-hospital mortality and significant bleeding and modest improvements in echocardiography-derived hemodynamic status. The timing of BVF is an important determinant of safety and efficacy.

Outcomes of Adults with Severe Aortic Stenosis Undergoing Urgent or Emergent vs. Elective Transcatheter Aortic Valve Replacement Within an Integrated Health Care Delivery System

Background

Transcatheter aortic valve replacement (TAVR) may be used to urgently or emergently treat severe aortic stenosis, but outcomes for this high-risk population have not been well-characterized. We sought to describe the incidence, clinical characteristics, and outcomes of patients undergoing urgent or emergent vs. elective TAVR.

Methods

We identified all adults who received TAVR for primary aortic stenosis between 2013 and 2019 within an integrated health care delivery system in Northern California. Elective or urgent/emergent procedure status was based on standard Society of Thoracic Surgeons definitions. Data were obtained from electronic health records, the Society of Thoracic Surgeons-American College of Cardiology Transcatheter Valve Therapy Registry, and state/national reporting databases. Logistic regression and Cox proportional hazard models were performed.

Results

Among 1564 eligible adults that underwent TAVR, 81 (5.2%) were classified as urgent/emergent. These patients were more likely to have heart failure (63.0% vs. 47.4%), reduced left ventricular ejection fraction (21.0% vs. 11.8%), or a prior aortic valve balloon valvuloplasty (13.6% vs. 5.0%) and experienced higher unadjusted rates of 30-day and 1-year morbidity and mortality. Urgent/emergent TAVR status was independently associated with non-improved quality of life at 30-days (hazard ratio, 4.87; p < 0.01) and acute kidney injury within 1-year post-TAVR (hazard ratio, 2.11; p = 0.01). There was not a significant difference in adjusted 1-year mortality with urgent/emergent TAVR.

Conclusions

Urgent/emergent TAVR status was uncommon and associated with high-risk clinical features and higher unadjusted rates of short- and long-term morbidity and mortality. Procedure status may be useful to identify patients less likely to experience significant short term improvement in health-related quality of life post-TAVR.

Valve-in-valve TAVI and risk of coronary obstruction: Validation of the VIVID classification

BACKGROUND

The Valve-in-Valve International Data (VIVID) registry proposed a simplified classification to assess the risk of coronary obstruction during valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) based on preprocedural multi-detector computed tomography (MDCT). We investigated the validity of the VIVID classification in patients undergoing ViV-TAVI for degenerated bioprostheses.

METHODS

Patients undergoing ViV-TAVI for degenerated bioprostheses were prospectively included in this study. The risk of coronary obstruction among patients treated with stented valves was retrospectively evaluated based on anatomical assessment on pre-procedural MDCT.

RESULTS

Among a total of 137 patients that underwent ViV-TAVI between August 2007 and June 2021, 109 patients had stented, sutureless, or transcatheter degenerated bioprosthesis of which 96 (88%) had adequate MDCT data for risk assessment. High-risk anatomy for coronary obstruction (VIVID type IIB, IIIB, or IIIC) in either the left or right coronary artery was observed in 30 patients (31.3%). Of the 30 patients with high-risk anatomy, coronary protection using wire protection or BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) was performed in 3 patients (10.0%). Three patients treated with stentless valves and one patient treated with a stented valve with externally mounted leaflets had coronary obstruction. None of the patients with high risk anatomy according to MDCT had coronary obstruction even without coronary protection.

CONCLUSIONS

Coronary obstruction occurred in none of the patients classified as high-risk patients according to the VIVID classification despite the absence of coronary protection. Refined tools are required to assess the risk of coronary obstruction.

CLINICAL TRIAL REGISTRATION

https://www.

CLINICALTRIALS

gov. NCT01368250.

BAlloon expandable vs. SElf expanding transcatheter vaLve for degenerated bioprosthesIs: design and rationale of the BASELINE trial

BACKGROUND

Surgical aortic valve bioprostheses may degenerate over time and require redo intervention. Transcatheter aortic valve replacement (TAVR) is a less invasive alternative to redo surgery. The BAlloon Expandable vs. SElf Expanding Transcatheter VaLve for Degenerated BioprosthesIs (BASELINE) trial was designed to compare the performance of the balloon-expandable SAPIEN-3 Ultra and the self-expanding EVOLUT PRO+ valve systems in symptomatic patients with a failing surgical bioprosthesis.

METHODS

The BASELINE trial is an investigator-initiated, non-funded, prospective, randomized, open-label, superiority trial enrolling a total of 440 patients in up to 50 sites in 12 countries in Europe and North-America. The primary endpoint is device success at 30-days defined by the Valve Academic Research Consortium-3 Criteria as the composite of technical success, freedom from mortality, freedom for surgery or intervention related to the device or to a major vascular or access-related or cardiac structural complication with an intended performance of the valve (mean gradient <20 mmHg and less than moderate aortic regurgitation). The co-primary endpoint at 1 year is defined as the composite of all-cause death, disabling stroke, rehospitalization for heart failure or valve related problems. Independent Core Laboratories will conduct uniform analyses of echocardiography (pre-, post-, 1-year post-procedure), multi-sliced computed tomography (pre-, and if available post-procedure) and cine-fluoroscopy studies.

CONCLUSIONS

The BASELINE trial is a head-to-head comparative trial investigating the 2 most used contemporary transcatheter heart valves for the treatment of a failing surgical aortic bioprosthesis. (ClinicalTrials.gov number NCT04843072).

Early and mid-term outcomes after aortic valve intervention in patients with previous stentless or stented bioprostheses

BACKGROUND

Limited data are available concerning comparative outcomes of redo aortic valve interventions, including surgery after aortic valve replacement (AVR) with either stented or stentless bioprostheses. We investigated the comparative outcomes of redo aortic valve interventions, including surgery after AVR with either stented or stentless bioprostheses.

METHODS

The cohort consisted of 112 patients who underwent aortic valve intervention for infective endocarditis or structural valve deterioration between 2001 and 2020. One hundred patients received a stented valve (stented group) and 12 patients received a stentless valve (stentless group) during the initial surgery. Early and late outcomes were evaluated.

RESULTS

The mean [IQR] ages during the current interventions were 66 [54, 77] years in the stented group and 74 [67, 79] years in the stentless group (P = 0.13). In the stented group, aortic valve interventions included redo AVRs with stented valves (n = 54), mechanical valves (n = 26), stentless valves (n = 16), and transcatheter aortic valve implantations (n = 4). In the stentless group, redo AVRs were performed with stented valves (n = 4), mechanical valves (n = 2), stentless valves (n = 1), and transcatheter valve implantations (n = 5). Hospital mortality was observed in 2 (2%) patients in the stented group and 1 (8%) patients in the stentless group (P = 0.29). The 5-year survival was 80.8% [66.8, 88.5] in the stented group and 91.7% [53.9, 98.8] in stentless group. Statistically significant differences in thromboembolisms were observed between the groups.

CONCLUSIONS

No significant differences in early and mid-term outcomes (except thromboembolism) after aortic valve interventions were detected between patients with stented and stentless AVRs.

Multicenter experience with valve-in-valve transcatheter aortic valve replacement compared with primary, native valve transcatheter aortic valve replacement

BACKGROUND

Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) offers an alternative to reoperative surgical aortic valve replacement. The short- and intermediate-term outcomes after ViV TAVR in the real world are not entirely clear.

PATIENTS AND METHODS

A multicenter, retrospective analysis of a consecutive series of 121 ViV TAVR patients and 2200 patients undergoing primary native valve TAVR from 2012 to 2017 at six medical centers. The main outcome measures were in-hospital mortality, 30-day mortality, stroke, myocardial infarction, acute kidney injury, and pacemaker implantation.

RESULTS

ViV patients were more likely male, younger, prior coronary artery bypass graft, "hostile chest," and urgent. 30% of the patients had Society of Thoracic Surgeons risk score <4%, 36.3% were 4%-8% and 33.8% were >8%. In both groups many patients had concomitant coronary artery disease. Median time to prosthetic failure was 9.6 years (interquartile range: 5.5-13.5 years). 82% of failed surgical valves were size 21, 23, or 25 mm. Access was 91% femoral. After ViV, 87% had none or trivial aortic regurgitation. Mean gradients were <20 mmHg in 54.6%, 20-29 mmHg in 30.6%, 30-39 mmHg in 8.3% and ≥40 mmHg in 5.87%. Median length of stay was 4 days. In-hospital mortality was 0%. 30-day mortality was 0% in ViV and 3.7% in native TAVR. There was no difference in in-hospital mortality, postprocedure myocardial infarction, stroke, or acute kidney injury.

CONCLUSION

Compared to native TAVR, ViV TAVR has similar peri-procedural morbidity with relatively high postprocedure mean gradients. A multidisciplinary approach will help ensure patients receive the ideal therapy in the setting of structural bioprosthetic valve degeneration.

Hemodynamic follow-up after valve-in-valve TAVR for failed aortic bioprosthesis

BACKGROUND

"valve-in-valve" TAVR (VIV-TAVR) is established and provides good initial clinical and hemodynamic outcomes. Lacking long-term durability data baffle the expand to lower risk patients. For those purposes, the present study adds a hemodynamic 3-years follow-up.

METHODS

A total of 77 patients underwent VIV-TAVR for failing aortic bioprosthesis during a 7-years period. Predominant mode of failure was stenosis in 87.0%. Patients had a mean age of 79.4 ± 5.8 years and a logistic EuroSCORE of 30.8 ± 15.7%. The Society of Thoracic Surgeons-PROM averaged 5.79 ± 2.63%. Clinical results and hemodynamic outcomes are reported for 30-days, 1-, 2-, and 3-years. Completeness of follow-up was 100% with 44 patients at risk after 3-years. Follow-up ranged up to 7.1 years.

RESULTS

Majority of the surgical valves were stented (94.8%) with a mean labeled size of 23.1 ± 2.3 mm and true-ID of 20.4 ± 2.6 mm. A true-ID ≤21 mm had 58.4% of the patients. Self-expanding valves were implanted in 68.8% (mean labeled size 24.1 ± 1.8 mm) and balloon-expanded in 31.2% (mean size 24.1 ± 1.8 mm). No patient died intraoperatively. Hospital mortality was 1.3% and three-years survival 57.1%. All patients experienced an initial significant dPmean-reduction to 16.8 ± 7.1 mmHg. After 3-years mean dPmean raised to 26.0 ± 12.2 mmHg. This observation was independent from true-ID or type of transcatheter aortic valve replacement (TAVR)-prosthesis. Patients with a true-ID ≤21 mm had a higher initial (18.3 ± 5.3 vs. 14.9 ± 7.1 mmHg; p = .005) and dPmean after 1-year (29.2 ± 8.2 vs. 13.0 ± 6.7 mmHg; p = .004). There were no significant differences in survival.

CONCLUSIONS

VIV-TAVR is safe and effective in the early period. In surgical valves with a true-ID ≤21 mm inferior hemodynamic and survival outcomes must be expected. Nonetheless, also patients with larger true-IDs showed steadily increasing transvalvular gradients. This raises concern about durability.

Looking Back to Look Forward: What to Expect in a Redo Surgery for a Bioprosthesis Replacement

Redo surgeries are becoming more common because of an increased rate of bioprosthesis implantation. We performed a retrospective study on patients who underwent redo replacement of an aortic and/or mitral bioprosthesis between 2005 and 2018 to evaluate intra-hospital mortality and morbidity. Univariate analysis was performed on the propensity score variables to determine predictors of mortality. A total of 180 patients were enrolled in the study: Group A (replacement of aortic bioprosthesis) with 136 patients (75.56%) and group B (replacement of mitral bioprosthesis ± aortic bioprosthesis) with 44 patients (24.44%). NYHA class ≥ 3 and female sex were significantly more common in group B. Cardiopulmonary-bypass time and aortic cross-clamping time in group A and group B were, respectively, 154.95 ± 74.35 and 190.25 ± 77.44 (p = 0.0005) and 115.99 ± 53.54 and 144.91 ± 52.53 (p = 0.0004). Overall mortality was 8.89%. After propensity score adjustment, Group B was confirmed to have an increased risk of death (OR 3.32 CI 95% 1.02−10.88 p < 0.0001), gastrointestinal complications (OR 7.784 CI 95% 1.005−60.282 p < 0.0002) and pulmonary complications (OR 2.381 CI 95% 1.038−5.46 p < 0.0001). At the univariate analysis, endocarditis, cardiopulmonary-bypass and aortic cross clamping time, NYHA class ≥ 3 and urgency setting were significantly associated to death. Intra-hospital outcomes were acceptable regarding mortality and complications. Patients who need redo surgery on mitral bioprosthesis have an increased risk of post-operative pulmonary and gastrointestinal complications and mortality. Therefore the choice of mitral bioprosthesis at time of first surgery should be carefully evaluated.

Transcatheter Aortic Valve Implantation for Bioprosthetic Valve Failure: Placement of Aortic Transcatheter Valves 3 Aortic Valve-in-Valve Study

Background

Transcatheter aortic valve implantation is safe and effective for high-risk patients with bioprosthetic valve failure (BVF) but has not been studied in low- and intermediate-risk patients. One year outcomes of the PARTNER 3 Aortic Valve-in-valve (AViV) Study were evaluated.

Methods

This prospective, single-arm, multicenter study enrolled 100 patients from 29 sites with surgical BVF. The primary endpoint was a composite of all-cause mortality and stroke at 1 year. The key secondary outcomes included mean gradient, functional capacity, and rehospitalization (valve-related, procedure-related, or heart failure related).

Results

A total of 97 patients underwent AViV with a balloon-expandable valve from 2017 to 2019. Patients were 79.4% male with a mean age of 67.1 years and Society of Thoracic Surgeons score of 2.9%. The primary endpoint occurred in 2 patients (2.1%) who had strokes; there was no mortality at 1 year. Five patients (5.2%) had valve thrombosis events, and 9 patients (9.3%) had rehospitalizations, including 2 (2.1%) for strokes, 1 (1.0%) for heart failure, and 6 (6.2%) for aortic valve reinterventions (3 explants, 3 balloon dilations, and 1 percutaneous paravalvular regurgitation closure). From baseline to 1 year, New York Heart Association class III/IV decreased from 43.3% to 4.5%, mean gradient from 39.1 ± 18.2 mm Hg to 19.7 ± 7.6 mm Hg, and ≥moderate aortic regurgitation from 41.1% to 1.1%.

Conclusions

AViV with a balloon-expandable valve improved hemodynamic and functional status at 1 year and can provide an additional therapeutic option in selected low- or intermediate-risk patients with surgical BVF, although longer term follow-up is necessary.

Transvalvular Pressure Gradients and All-Cause Mortality Following TAVR: A Multicenter Echocardiographic and Invasive Registry

BACKGROUND

Low ejection fraction (EF) and low flow as determined by an echocardiographic stroke volume index (SVi) <35 mL/m² are associated with low transvalvular gradients and increased mortality in both severe aortic stenosis (AS) and post-transcatheter aortic valve replacement (TAVR). Absence of an elevated echocardiographic transaortic gradient post-TAVR is considered a marker of procedural success despite the absence of data on its impact on mortality.

OBJECTIVES

The authors sought to examine the association of invasive and echocardiographic gradients post-TAVR with all-cause mortality in relation to flow and EF.

METHODS

In a multicenter retrospective registry of patients undergoing TAVR, Cox models with regression splines explored the relationship between invasive and echocardiographic gradients post-TAVR with 2-year mortality. An invasive gradient <5 mm Hg was considered low, between ≥5 and <10 mm Hg was considered intermediate, and ≥10 mm Hg was considered high. An echocardiographic gradient <10 mm Hg was considered low, ≥10 and <20 mm Hg was considered intermediate, and ≥20 mm Hg was considered high.

RESULTS

Higher mortality occurred in low echocardiographic gradients at discharge relative to intermediate gradients (P < 0.001), and low gradient was associated with lower EF and echocardiographic SVi (P < 0.001 and P < 0.008, respectively). Lower mortality occurred in low invasive gradients relative to intermediate gradients (P = 0.012) with no difference in EF and echocardiographic SVi between groups (P = 0.089 and P = 0.947, respectively). There were insufficient observations to determine the impact of high echocardiographic and invasive gradients on mortality.

CONCLUSIONS

In this large retrospective analysis, the impact of transaortic gradients on mortality after TAVR was not linear and complex, showing opposite results among echocardiographic and invasive measurements in low-gradient patients.

Surgical Management of Complex Aortic Valve Disease in Young Adults: Repair, Replacement, and Future Alternatives

The ideal aortic valve substitute in young adults remains unknown. Prosthetic valves are associated with a suboptimal survival and carry a significant risk of valve-related complications in young patients, mainly reinterventions with tissue valves and, thromboembolic events and major bleeding with mechanical prostheses. The Ross procedure is the only substitute that restores a survival curve similar to that of a matched general population, and permits a normal life without functional limitations. Though the risk of reintervention is the Achilles' heel of this procedure, it is very low in patients with aortic stenosis and can be mitigated in patients with aortic regurgitation by tailored surgical techniques. Finally, the Ozaki procedure and the transcatheter aortic valve implantation are seen by many as future alternatives but lack evidence and long-term follow-up in this specific patient population.

TAVR for All? The Surgical Perspective

In spite of the noninferiority of transcatheter aortic valve replacement (TAVR) in high- and intermediate-risk patients, there are still obstacles that need to be overcome before the procedure is further expanded and clinically integrated. The lack of evidence on the long-term durability of the bioprostheses used for TAVR remains of particular concern. In addition, surgery may be preferred over TAVR in patients with bicuspid aortic valve (BAV) or with concomitant pathologies such as other valve diseases (mitral regurgitation/tricuspid regurgitation), aortopathy, and coronary artery disease. In this review, we discuss and summarize relevant data from clinical trials, current trends, and remaining obstacles, and provide our perspective on the indications for the expansion of TAVR.

Transcatheter Mitral Valve-in-Valve Implantations Using Inverted J-Valve

Background

As bioprosthetic valves are being widely used, the incidence of structural valve deterioration increases, as well as the need for reoperation. Transcatheter mitral valve-in-valve implantations are being increasingly adopted as an alternative to redo-surgical mitral replacement for patients with high surgical risks. This study reports a series of transcatheter mitral valve-in-valve implantations using inverted J-valves.

Methods

From April 2019 to September 2021, 17 symptomatic high-risk patients with mitral bioprosthetic valve dysfunction underwent transapical transcatheter mitral valve-in-valve implantations using inverted J-valves at our institution.

Results

The median age was 70 years, with 76.5% being female. The median Society of Thoracic Surgeons predicted risk of mortality (STS PROM) was 17.2% (8.7–82.24%). All patients had successful transapical transcatheter mitral valve-in-valve implantations except for one intraoperative death due to left ventricle rupture. Four patients underwent simultaneous transcatheter aortic valve implantation, two of which had valve-in-valve transcatheter aortic valve implantation. There was no major complication except one case of bleeding. Thirty-day mortality was 11.8% (2/17), and 90-days mortality was 23.5% (4/17). Percentages of patients with New York Heart Association class III/IV symptoms decreased from 100 (17/17) to 20% (3/15) at 30-days. Median mitral inflow velocity was 1.95 mm/s at 30 days, compared to 2.7 mm/s at baseline. Median mitral valve effective orifice area increases from 1.5 mm at baseline to 1.85 mm at 30 days.

Conclusion

Transcatheter transapical valve-in-valve implantations with J-valve can be a plausible solution to failed mitral bioprosthesis with acceptable results for high-risk patients.

The role of mechanical valves in the aortic position in the era of bioprostheses and TAVR: Evidence-based appraisal and focus on the On-X valve

Patients who need a prosthetic aortic heart valve may decide, working with their cardiologist and cardiac surgeon, among a variety of options: surgical or transcatheter approach, bioprosthetic or mechanical valve, or a Ross procedure if suitable to their age and anatomy. This review article examines the evidence for survival benefit with mechanical aortic valves, discusses bioprosthetic structural valve degeneration and its consequences, and considers the risks of redo aortic valve surgery or subsequent valve-in-valve (ViV) transcatheter intervention. It highlights the unique characteristics of the On-X aortic valve, including the US Food and Drug Administration approved and American College of Cardiology/American Heart Association guideline supported reduced anticoagulation target INR of 1.5 to 2.0, and discusses the PROACT Xa trial comparing apixaban vs warfarin anticoagulation. The choice of prosthetic valve should be individualized, carefully considering each patient's unique circumstances. In that context, the On-X aortic valve offers a potential lifetime solution without need for a repeat operation, while minimizing the risks of long-term anticoagulation. In an era of enthusiasm for bioprosthetic and transcatheter-based approaches, the option of a second-generation bileaflet mechanical valve with optimized hemodynamics-the On-X aortic valve-may well align with patient expectations.

Transcatether Aortic Valve Implantation to Treat Degenerated Surgical Bioprosthesis: Focus on the Specific Procedural Challenges

Actually transcatheter aortic valve implantation within failed surgically bioprosthetic valves (VIV-TAVI) is an established procedure in patients at high risk for repeat surgical aortic valve intervention. Although less invasive than surgical reintervention, VIV-TAVI procedure offers potential challenges, such as higher rates of prosthesis-patient mismatch and coronary obstruction. Thus, optimal procedural planning plays an important role to minimize the risk of procedure complications. In this review, we describe the key points of a VIV-TAVI procedure to optimize outcomes and reduce the risk of procedure complications.

Current surgical bioprostheses: Looking to the future

The utilization of bioprostheses for surgical heart valve replacement has been increasing across all age groups. For patients, the appeal of the bioprosthetic valve rests with the avoidance of anticoagulation, fewer thrombotic and hemorrhagic events, and the increasing availability of transcatheter valve-in-valve interventions -both in the aortic and mitral positions- allowing for lower morbidity reinterventions. While improvements in valve hemodynamics and long-term durability have made bioprostheses a reasonable choice for a growing number of patients, challenges do remain. With increasing usage of bioprostheses, especially in younger patients, there will be an increase in the projected number of failing bioprosthetic valves. This trend will bring even more emphasis to maximizing long-term durability, optimizing anticoagulation, and promoting patient-level decision making around prosthesis choice.

Outcomes in Valve-in-Valve Transcatheter Aortic Valve Implantation

The use of valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) is increasing, but studies evaluating clinical outcomes in these patients are scarce. Also, there are limited data to guide the choice of valve type in ViV-TAVI. Therefore, this CENTER-study evaluated clinical outcomes in patients with ViV-TAVI compared to patients with native valve TAVI (NV-TAVI). In addition, we compared outcomes in patients with ViV-TAVI treated with self-expandable versus balloon-expandable valves. A total of 256 patients with ViV-TAVI and 11333 patients with NV-TAVI were matched 1:2 using propensity score matching, resulting in 256 patients with ViV-TAVI and 512 patients with NV-TAVI. Mean age was 81±7 years, 58% were female, and the Society of Thoracic Surgeons Predicted Risk of Mortality was 6.3% (4.0% to 12.8%). Mortality rates were comparable between ViV-TAVI and NV-TAVI patients at 30 days (4.1% vs 5.9%, p = 0.30) and 1 year (14.2% vs 17.3%, p = 0.34). Stroke rates were also similar at 30 days (2.8% vs 1.8%, p = 0.38) and 1 year (4.9% vs 4.3%, p = 0.74). Permanent pacemakers were less frequently implanted in patients with ViV-TAVI (8.8% vs 15.0%, relative risk 0.59, 95% confidence interval [CI] 0.37 to 0.92, p = 0.02). Patients with ViV-TAVI were treated with self-expandable valves (n = 162) and balloon-expandable valves (n = 94). Thirty-day major bleeding was less frequent in patients with self-expandable valves (3% vs 13%, odds ratio 5.12, 95% CI 1.42 to 18.52, p = 0.01). Thirty-day mortality was numerically lower in patients with self-expandable valves (3% vs 7%, odds ratio 3.35, 95% CI 0.77 to 14.51, p = 0.11). In conclusion, ViV-TAVI seems a safe and effective treatment for failing bioprosthetic valves with low mortality and stroke rates comparable to NV-TAVI for both valve types.

Valve-in-valve transcatheter aortic valve replacement or re-surgical aortic valve replacement in degenerated bioprostheses: A systematic review and meta-analysis of short and midterm results

INTRODUCTION

Despite limited to short and midterm outcomes, valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) has emerged as a valid alternative to re-surgical aortic valve replacement (re-SAVR) for high- and intermediate-risk patients with degenerated surgical bioprosthesis.

METHODS

All studies comparing multivariate adjustment between ViV TAVI and re-SAVR were screened. The primary end-points were all-cause and cardiovascular (CV) mortality at 30 days and at Midterm follow-up. Short-term complications were the secondary endpoints.

RESULTS

We obtained data from 11 studies, encompassing 8570 patients, 4224 undergoing ViV TAVI, and 4346 re-SAVR. Four studies included intermediate-risk patients and seven high-risk patients. 30-day all-cause and CV mortality were significantly lower in ViV (odds ratio [OR] 0.43, 95% confidence intervals [CIs] 0.29-0.64 and OR 0.44, 0.26-0.73 respectively), while after a mean follow-up of 717 (180-1825) days, there was no difference between the two groups (OR 1.04, 0.87-1.25 and OR 1.05, 0.78-1.43, respectively). The risk of stroke (OR 1.03, 0.59-1.82), MI (OR 0.70, 0.34-1.44), major vascular complications (OR 0.92, 0.50-1.67), and permanent pacemaker implantation (OR 0.67, 0.36-1.25) at 30 days did not differ, while major bleedings and new-onset atrial fibrillation were significantly lower in ViV patients (OR 0.41, 0.25-0.67 and OR 0.23, 0.12-0.42, respectively, all 95% CIs).

CONCLUSIONS

In high- and intermediate-risk patients with degenerated surgical bioprostheses, ViV TAVI is associated with reduced short-term mortality, compared with re-SAVR. Nevertheless, no differences were found in all-cause and CV mortality at midterm follow-up. PROSPERO CRD42021226488.

Early- and mid-term outcomes of reinterventions for aortic bioprosthesis failure

BACKGROUND

The aim of this study was to evaluate early- and mid-term results of our actual practice embedding redo aortic valve replacement and transcatheter procedures for aortic bioprosthetic failure.

METHODS

Data for aortic valve reinterventions (redo surgical aortic valve replacement, isolated redo aortic valve replacement, and valve-in-valve transcatheter aortic valve implantation, transcatheter valve-in-valve procedure) were collected (2010-2019). Logistic regression analysis was performed to identify predictors favouring the choice of transcatheter against redo surgery. Cox analysis was used to study the association of preoperative variables with survival. Survival probabilities were calculated with Kaplan-Meier analysis and compared using a log-rank test.

RESULTS

A total of 125 patients were included (redo surgical aortic valve replacement: 84 patients, valve-in-valve transcatheter aortic valve implantation: 41 patients). Median age was 74 [63-80] years, 58% of the patients were male and the median logistic EuroSCORE was 15 [8-26] %. There was no early mortality. Eighteen patients (redo surgical aortic valve replacement: 15, valve-in-valve transcatheter aortic valve implantation: 3) sustained at least one postoperative complication. At pre-discharge transthoracic echocardiogram, valve-in-valve transcatheter aortic valve implantation had significantly higher trans-prosthetic gradients (mean gradient: valve-in-valve transcatheter aortic valve implantation 18 mmHg vs. redo surgical aortic valve replacement 14 mmHg, p < 0.001). Overall survival probabilities were 94% and 73% at 1 year and 5 years, respectively. Previous coronary artery bypass surgery operation and age were independently associated with lower survival probabilities during the follow-up.

CONCLUSIONS

Redo surgical aortic valve replacement and valve-in-valve transcatheter aortic valve implantation are both safe and effective for aortic bioprosthetic failure. Further valve-in-valve data are needed to determine the haemodynamic performance of transcatheter prostheses and its impact on long-term outcomes.

5-Year Follow-Up From the PARTNER 2 Aortic Valve-in-Valve Registry for Degenerated Aortic Surgical Bioprostheses

OBJECTIVES

The aim of this study was to report the outcomes of valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) at 5 years.

BACKGROUND

TAVR for degenerated surgical bioprostheses in patients at high risk for reoperative surgery is an important treatment option that may delay or obviate the need for surgical intervention; however, long-term outcomes of this procedure are unknown.

METHODS

The PARTNER (Placement of Aortic Transcatheter Valves) 2 ViV and continued access registries prospectively enrolled patients with failed surgical bioprostheses at high risk for reoperation. Five-year clinical and echocardiographic follow-up data were obtained in 95.9% of patients.

RESULTS

In 365 (96 registry and 269 continued access) patients, the mean age was 78.9 ± 10.2 years, the mean Society of Thoracic Surgeons predicted risk of surgical mortality score was 9.1 ± 4.7%, and New York Heart Association functional class was III or IV in 90.4%. At 5 years, the Kaplan-Meier rates of all-cause mortality and any stroke were 50.6% and 10.5%, respectively. Using Valve Academic Research Consortium 3 definitions, the incidence of structural valve deterioration, related hemodynamic valve deterioration, or bioprosthetic valve failure at 5 years was 6.6%. Aortic valve re-replacement was performed in 6.3% (n = 14), the majority of which was due to stenosis (n = 6) and combined aortic insufficiency/paravalvular regurgitation (n = 3). The mean gradient, Doppler velocity index, paravalvular regurgitation, and quality of life measured by Kansas City Cardiomyopathy Questionnaire scores in survivors remained stable from 30 days postprocedure through 5 years.

CONCLUSIONS

At the 5-year follow-up, TAVR for bioprosthetic aortic valve failure in high surgical risk patients was associated with sustained improvement in clinical and echocardiographic outcomes.

Valve-in-valve Transcatheter Aortic Valve Replacement for Failed Surgical Valves and Adjunctive Therapies

While redo surgical aortic valve replacement has traditionally been the gold standard for the treatment of failed surgical valves, valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) has arisen as a viable, less invasive option with the potential for improved short-term morbidity and mortality. Retrospective registry data regarding ViV TAVR outcomes have been encouraging, with excellent 1-year mortality, and sustained valve performance and quality of life improvement out to 3 years. Operators must be comfortable with CT analysis for procedural planning, and be able to identify and troubleshoot patients who are at risk for coronary obstruction and patient prosthesis mismatch. The authors provide a review of clinical outcomes associated with ViV TAVR, procedural planning recommendations, and strategies to overcome technical challenges that can occur during ViV TAVR.

Trans-Catheter Valve-in-Valve Implantation for the Treatment of Aortic Bioprosthetic Valve Failure

Aortic valve-in-valve (ViV) procedure is a valid treatment option for patients affected by bioprosthetic heart valve (BHV) degeneration. However, ViV implantation is technically more challenging compared to native trans-catheter aortic valve replacement (TAVR). A deep knowledge of the mechanism and features of the failed BHV is pivotal to plan an adequate procedure. Multimodal imaging is fundamental in the diagnostic and pre-procedural phases. The main challenges associated with ViV TAVR consist of a higher risk of coronary obstruction, severe post-procedural patient-prosthesis mismatch, and a difficult coronary re-access. In this review, we describe the principles of ViV TAVR.

Lifetime management for aortic stenosis: Planning for future therapies

A shift to lifetime management has gained more focus with the approval of low-risk transcatheter aortic valve replacement (TAVR). This paper is therefore focused on the different approaches for lifetime management. Herein we discuss the procedural safety, durability, performance, and future options for each lifetime management strategy. In younger patients that elect to undergo surgical aortic valve replacement (SAVR), options for bioprosthetic failure are TAV-in-SAV or redo SAVR. Among patients that undergo TAVR, options for valve failure include TAVR explant with SAVR or TAV-in-TAV. Additionally, there are patients who may require a third valvular intervention. The initial therapy may limit re-intervention options down the road. This review discusses how options for future therapies affect the decision of SAVR vs TAVR in younger patients.

Transcatheter aortic valve implantation for degenerated surgical aortic bioprosthesis: A systematic review

Background:

Transcatheter aortic valve in valve (Aviv) replacement has been shown to be an effective therapeutic option in patients with failed aortic bioprosthetic valves. This review intended to evaluate contemporary 1-year outcomes of Aviv in recent studies.

Methods:

A systematic review on outcomes of Aviv was performed using the best available evidence from studies obtained using a MEDLINE, Cochrane database, and SCOPUS search. Endpoints of interest were survival, coronary artery obstruction, prosthesis-patient mismatch (PPM), stroke, pacemaker implantation, and structural valve deterioration.

Results:

A total of 3339 patients from 23 studies were included. Mean age was 68–80 years, 20%–50% were female, and Society of Thoracic Surgeons score ranged from 5.7 to 31.1. Thirty-day all-cause mortality ranged from 2% to 8%, and 1-year all-cause mortality ranged from 8% to 33%. Coronary artery obstruction risk after Aviv ranged from 0.6% to 4%. One-year stroke ranged from 2% to 8%. Moderate-severe PPM occurred in 11%–58%, and pacemaker rate at 1 year ranged from 5% to 12%.

Conclusion:

Transcatheter aortic ViV has emerged as an effective therapeutic option to treat patients with failed bioprostheses. The acceptable complication rate and favorable 1-year outcomes make Aviv an appropriate alternative to redo surgical aortic valve replacement.

Transcatheter aortic valve replacement (TAVR): Recent updates

Within the last two decades, transcatheter aortic valve replacement (TAVR) has revolutionized the management of symptomatic severe aortic stenosis (AS). Newer generations of transcatheter valve design, optimized imaging planning, growing operator experience, and technical refinements have driven enhancements in safety and reduction of procedural complications over time. These improvements have allowed expansion to lower risk patients, in which TAVR confirmed favorable outcomes compared to surgical aortic valve replacement (SAVR). Based on current evidence, the 2020 AHA/ACC guidelines provided updated recommendations on indications for TAVR, with several clinical indications remain with SAVR. As TAVR expands to younger, low-risk patients with longer life expectancies, different issues of utmost importance have emerged, such as long-term durability, bioprosthetic valve performance, coronary reaccess, prognostic impact of conduction disturbances and paravalvular leak, reintervention after TAVR, and optimal pharmacological management after the procedure. In this review, we provide an update of recent clinical guidelines and available data from clinical trials and registries, and highlight novel strategies to further reduce procedural complications.